Where to Refer for CBT-I
Refer your 40-year-old male patient with insomnia to a trained professional who can deliver multicomponent cognitive behavioral therapy for insomnia (CBT-I), which should be accessed through the Society of Behavioral Sleep Medicine (www.behavioralsleep.org) or practitioners certified by the American Board of Sleep Medicine (www.absm.org). 1, 2
Primary Referral Resources
The Society of Behavioral Sleep Medicine and the American Board of Sleep Medicine maintain directories of practitioners with expertise in CBT-I delivery. 2 These are the most reliable sources for finding clinicians trained in evidence-based insomnia treatment, as CBT-I requires specific training beyond general psychotherapy credentials.
Who Can Deliver CBT-I
The American Academy of Sleep Medicine's strong recommendation for CBT-I is based primarily on studies where treatment was delivered by a trained professional. 1 This typically includes:
- Behavioral sleep medicine specialists certified through the American Board of Sleep Medicine 2
- Clinical psychologists with specialized training in CBT-I 3
- Mental health professionals who have completed formal CBT-I training programs 4
Treatment Structure and Timeline
Your patient should expect 4-8 sessions delivered over several weeks by the trained clinician. 4, 3 The treatment will include multiple core components:
- Sleep restriction therapy: Limiting time in bed to match actual sleep time (minimum 5 hours) to achieve >85% sleep efficiency 4
- Stimulus control therapy: Using the bedroom only for sleep and sex, leaving if unable to sleep within 15-20 minutes, maintaining consistent sleep-wake times 4
- Cognitive therapy: Challenging dysfunctional beliefs like "I can't sleep without medication" or "My life will be ruined if I can't sleep" 4
- Relaxation training: Progressive muscle relaxation, guided imagery, or diaphragmatic breathing 4
- Sleep hygiene education: Addressing environmental factors and behaviors that disrupt sleep 4
Alternative Delivery Methods When In-Person Access Is Limited
While the evidence is strongest for in-person delivery by trained professionals, telehealth platforms and provider-directed telemedicine are potential strategies for increasing access to CBT-I when face-to-face treatment is not available. 1 However, the VA/DoD guidelines concluded there was insufficient evidence to recommend for or against Internet-based or group delivery compared with face-to-face treatment. 1
Internet-delivered CBT-I (eCBT-I) has shown effectiveness in multiple studies, though it may face challenges with patient engagement and digital literacy. 5 This can serve as an alternative when trained professionals are not geographically accessible.
Expected Outcomes and Important Counseling Points
Warn your patient that temporary daytime fatigue, sleepiness, mood impairment, or cognitive difficulties may occur during early treatment phases, but these resolve by the end of treatment. 1, 4 This is critical counseling to prevent premature discontinuation.
Treatment gains are durable for up to 2 years without need for additional interventions, which is a major advantage over pharmacotherapy. 1, 4 The American Academy of Sleep Medicine's strong recommendation is based on moderate-quality evidence from 49 randomized controlled trials showing clinically meaningful improvements in remission rates, responder rates, sleep quality, sleep latency, and wake after sleep onset. 1
Critical Pitfall to Avoid
Never initiate pharmacotherapy before attempting CBT-I, as behavioral interventions provide superior long-term outcomes and avoid medication-related risks including dependence, tolerance, and rebound insomnia. 4 The American Academy of Sleep Medicine recommends pharmacological therapy only after CBT-I alone has been unsuccessful. 4
For your 40-year-old male with no comorbidities, CBT-I is particularly appropriate as meta-analyses demonstrated clinically significant improvements in sleep quality, sleep latency, and wake after sleep onset specifically in patients with insomnia and no comorbidities. 1